pushing the needle too far

Today, I was in clinic and a notorious patient came in to be seen. A review of the chart had a slew of documentation preparing me from what could be in store- various encounters in which Mr. W had dismissed doctor after doctor at the VA where I sometimes train. His complaints had ranged from typical ones like frustration at the difficulties of navigating the system, to more telling ones, like accusations that he was receiving substandard care because he was at a 'teaching' hospital and that none of his doctors knew what they were doing because they were foreigners.

This is not unusual in the practice of medicine.

Mr. W had tangled with his last physician in my clinic, and it had gotten ugly quickly. He had asked her to write down her diagnosis. She had put it on a piece of paper in admittedly small and fine print, and Mr. W had peered at it with his poor eyesight and declared, "what is this, in Chinese? I can't read this." The doctor who had seen him that day, another fellow in my program, had reacted. She called him out flatly for what she had taken to be an ethnic slur. Mr. W subsequently flipped, and said "if you were born in this country, you'd know that's a common saying; people say it all the time."

As he recounted the incident to me, I wanted to tell him that I, in fact, was born in this country, and I said no such all the time.

But I grew up in EBF. The advantage and misfortune of my upbringing is that I can dissolve into a wall. I can seem non-judgmental, I can adjust, I can bob and weave, and I can avoid such missives hurtled in my direction. The blessing in that is it allows me to do my job. The curse is that I have to listen to the ugliness that lives in the deepest places in some people's hearts.

Mr. W is dying. He has a form of leukemia for which he cannot be treated, and just to add insult to injury, he has a solid tumor that has spread past its original site. He is dying without a doubt. And this is also par for the course in my clinic. Many of my patients are dying. Every one of them deals with death and mortality in their own way. Mr. W's way was to lash out and throw blame at anyone who he viewed as not his people.

Were I treating diabetes or back pain or arthritis, I might react differently I suppose. I might react like my colleague and tell the man he couldn't say such horrible things. But he is dying, and trying to school him on the ways of the world was not compatible with my job today. And so I listened to him list out every one of his grievances. I did not tell him any of his grievances were justified. I did not condone him. I just wanted to do my job. The man needed a blood transfusion, and he also needed to go to the hospital because his kidneys were now failing.

By the end of our visit, he took my hand so that he could make his way to the desk to sign his consent to receive blood. But I have no doubt in my mind, not even the slightest, that tomorrow he will be complaining about me, and talking about me as a foreigner too. I will be on that list of grievances soon enough. I know that. But I don't ever want to think I didn't treat someone to the best of my abilities because of their beliefs.

What I don't know is whether Mr. W is typically this racist, or if his illness had brought out all his distrust and underlying biases, things he would have otherwise suppressed as inappropriate. And it made me think about this country and the moment we're having. How there is so much hate and rage in the world. In clinic today, one of the other fellows was reading off headlines from his desk-

LA schools shut down due to threat of violence
Unarmed man shot in Butte County by police officer, caught on tape
Man with gun seen on Purdue University Campus
Man with road rage drives into front of hotel

I had this reflexive reaction to laugh, because that is what I do when things get this bad, when it's almost absurd. I sputtered out, "what is going on?" He looked drained as he just shrugged at me, as if to say we could only expect more of the same. And that does seem to be true. But why? Why has it gotten this bad? What cancer do we as a society have lurking inside of us that is causing these inherent biases and frontal disinhibition? Because something is going on.

In California, don't think we are immune to backwards thinking, because we are not. All the time, among my colleagues, who are highly educated white men, I listen to them bemoan the cultural competency classes they have to attend, and the unfairness of having to give a job to a minority or a woman. I have listened to them talk about how it is not right that they have to hire a minority or a woman when they 'click' more with a white male applicant. One white attending, who considers himself forward-thinking, said "it's hard out there for white men, we have to be so careful about what we say."

I wanted to ask why. Why is it so hard? Why do you have to be so careful? I manage to get through my entire day, every day, seven days a week, without saying something insensitive or inappropriate or borderline/totally racist. It takes hardly any effort at all. Why is it so hard for them? And why don't they ask themselves that question? What would be so horrible about admitting there was a problem?

Mr. W told me today the only physician worth a damn in this place was, predictably, the one white physician he had seen. Now, I know that physician, and he is a good doctor. But so was the Chinese woman Mr. W saw last week, and so were many of the other physicians he had seen. The other white men who are physicians, with whom I work, they think it is amusing when these patients come in with their racist ramblings, with their extreme distrust, with their demands to see an American doctor. They don't acknowledge that this is the very definition of white privilege; they don't recognize the toll such patient encounters take on the rest of us. Or that this is why even as a South Asian-American, which, let's not kid ourselves, is still a place of a lot of privilege, especially in the medical field, I remain at a disadvantage to my white colleagues. They will score higher on patient satisfaction surveys, frequently, just because of the color of their skin, and not once will they acknowledge that this is why they score higher. Partly, it's because we all work hard. Partly, it's because they've been raised to believe they are exceptional, and so they believe everything they've gotten is simply because they are better. And partly, it's because it's just a lot easier to believe it's fair than to acknowledge an inherent problem.

When you're living in one of the most liberal parts of the country, and you work in a profession that is at least 50% represented by women, it's disheartening to realize how far there is still to go.

My friends and I were talking once about what the cut off should be. We were talking about how, as physicians, we let a lot slide, especially in the way of inappropriate remarks, when it came from an elderly patient. We dismissed a lot by attributing their behavior to a different time in the world, when such thinking was more commonplace. We said eventually that population would simply age out, and we wouldn't have to tolerate racism and chauvinism from our older patients 10 or 20 years from now. But lately I am starting to think that's not true.

This is all jumbled up, as are my thoughts, as is my life. it's all connected, my microcosm somehow does seem to be a reflection of bigger issues. But I'm too tired to connect the dots just now. I'll keep trying to treat the racists and chauvinist pigs who have cancer. Maybe some day, someone will recognize the effort that takes.

one flame, one bonfire, let it burn higher

I was wondering why I haven't been writing here lately. When other people have cited reasons for shutting down their blogs, they have mentioned that they are either too busy or too passionate about what they are doing to spend time on writing. And I am busy, and I do spend a lot of time writing rather dry, medical things for work. But there's more than that at play now.

There is so much going on in the world. And in my world too. It has become increasingly hard to write about some random piece of entertainment, or some random thought I've been pondering, without thinking of how insensitive it is in comparison to big things. Big things like violence and illness and injustice and inequity. It's often seemed best to just stop typing instead of typing something inconsequential when so much of consequence is occurring.

But then you watch a movie like Creed.

I know. That seems laughable. But the thing is, it matters. In America, in our culture, it just matters. Entertainment is our outlet, but it also influences our thinking, our perceptions. It even plays into how we see ourselves. It does this in ways small and large. I suppose even if none of that were true, sometimes you just have to write about what moves you. And Creed did, believe it or not.

Creed is an audacious movie, as much as it is also a formulaic one. If you want to see it as a by-the-numbers boxing movie, it's got all the requisite notes that make it clear this is a movie that can be seen as a Rocky sequel. It has the underdog, the coach who takes a chance on a kid, the love interest, the brash opponent, and the epic final match. And it does all of those things so deftly, it's easy to forget that the plot is very close to a remake of the original Rocky.

But consider what this movie is saying. Spoilers follow, but they will not really change your enjoyment of the film. The movie opens with a juvenile detention center that disturbingly resembles a high-security prison with a bunch of African-American boys who look like boys. Like true boys. And that alone is a halting visual. The movie does not flinch from the fact that there is a broken system here that dooms the majority of these young men.

And then consider that the main character has a lot of promise, but needs someone to take a chance on him. Rocky's cousin works in a local gym in Philadelphia, has been trying to get him to train his son, but ultimately, Rocky ends up choosing to work with Adonis Johnson. Yes, on one level, this is the story of how Rocky trains Apollo Creed's son to redeem himself for his perceived guilt in Creed's death. But on the other hand, and maybe this is because I've read too much about this movie going into it, but this is also the story about diversity, and how diversity happens.

In order for diversity to happen, someone has to open the door in order for you to put your foot through, and then you have to be able to stand in the room and be worthy of it (at the least, usually you have to be more than worth it, but that's a story for another time). This is as true in Hollywood as it is in science and anywhere else. Even though I hit a brick wall in STEM, and ultimately switched my leanings towards medicine, where it turns out I belong, before I hit that wall, I had a lot of people along the way who did help and encourage and gave me opportunities- I just got to the final door and it was shut. But it doesn't mean I don't appreciate those mentors, who were mostly white men, who came before them, who did help me, and who ultimately also helped me when it came time for me to switch course. I'm not grateful to them in a sense of 'oh thank you, for deigning to believe in me'. I'm grateful that they were recognizing a problem, the problem being that women did not feel welcome in the basic sciences, and were doing what they could to correct it. In the case of Creed, it isn't quite so dramatic. But Ryan Coogler pitched Creed to Sylvester Stallone, and he initially turned it down. But when Fruitvale Station came out, Stallone changed his mind and was on board.

That's not nothing on so many levels. Stallone previously had creative control, had written and directed all of the Rocky movies, for better or worse. So it's an act of trust and generosity to let someone else have a shot at it. And for that someone to be a person of color, well, that is not nothing.

You can see Coogler's love of Rocky all over Creed. Yet though the movie reveres Rocky, it makes room, it clears a space for a new lead. This is not a movie about a white guy who is a hero because he trains a black kid. If you really want to compare it to some trope, this is a superhero origin story. And the superhero is Creed, not Rocky. Even the last shot of the movie puts Adonis front and center with Rocky standing to the side. Supporting but not overshadowing, not taking all the credit. That is a thing to see.

Then think of this- how rare it is to see in a recent movie two people separated by several decades in age, neither of them trying to be older or younger than they are, and both of them benefiting from their relationship? This movie celebrates youth but also the wisdom that comes with age. This movie, to be flippant about it, respects its elders. But it's also grounded in the now in so many ways.

The fact is, the Rocky movies were never popular because everyone loves boxing. We never watched professional boxing growing up, but my family watched all the Rocky movies with fervor. Boxing keeps getting featured in movies because it is dramatic and because there's something essential about it. Creed gets to the heart of that, as Rocky explains to Adonis that you're really fighting yourself in the ring. The opponent is there in the movies because an internal conflict is not as entertaining on the screen. This movie's theme is about finding a reason to fight and then having the courage to give it everything you can, and every person in the movie is fighting for something, and it's the right thing. Even the supposed 'villain.' This is not Rocky IV. Everyone wins in some way or another.

And then, there is a whole different level to this movie. And that's what is playing out in the theaters. I went to see this movie in a town in California that is truly one of the most diverse places in America, in every sense, not just in terms of race but in terms of socioeconomics. All of Thanksgiving weekend, I had been trying to get some Indian friends to see Creed with me, and they all wanted to see the new James Bond movie or the new Hunger Games movie. In fact, they were a little offended that I would rather see Creed. It's interesting to me, this South Asian tendency to lean towards identifying with white culture (except, of course, when it comes to rap music, in which case, South Asians suddenly become Straight Outta Compton). But honestly, I just identify more with Creed (it didn't hurt that a hospital scene had some throwaway scenes with an Indian doctor who got to have an Indian name and no accent), and I've realized these small things matter. I am not giving my money to big studio films that don't reflect what America or the world look like, not anymore. I see those movies sometimes on television, but box office matters. And I was nearly giddy sitting in the theater today which was chock full of people of so many different ethnicities. We have a voice, we have a say, and we can and do vote with our wallets. Creed looks like it is going to be the #3 box office this weekend, which is good, but after watching the movie, it should be #1, and it should stay that way for weeks to come.

I think of how those Rocky movies have mattered to me, as a child and as an adult. They were about a lunkhead who didn't have much going for him but his heart and sheer will to keep at it. Strangely, that's meant something to me at various difficult times in my life. The new hero, Creed, has more complex things to say and says them well, and I feel like it makes a difference in ways that we don't even understand right now. And in this increasingly horrible world where so many terrible things are happening, we need art to give us hope sometimes, and to open our eyes at other times. So I don't care if it's just a dumb piece of entertainment. I've got no regrets, except I wish you had seen Creed too.

I held my breath and you said something

Once upon a time, and it feels very much like a once upon a time situation in the sense of how far back (but not really, not really), I lived in a breathtakingly beautiful city. Inescapably beautiful. Punch-you-in-the-face, Tim-Riggins, Jordan-Catalano beautiful. My daily drive to and from work was an art school short film.

When you live in such a place, I think you tend to become lazy. You are used to the constant assault of picture perfection. Just before I left, I could walk down the street without being knocked off my feet. In the beginning, I remember talking with my brother at a rooftop party in San Francisco and blurting out, waving at the vistas all around me (and admittedly a little better with the help of spirits), "I think we've found the promised land!"

Which, in retrospect, is interesting, because it wasn't the promised land at all. It was a perfect moment. There is no promised land, I'm sorry to say. But there are perfect moments. Some of them are big. Like when you say goodbye to your best friend in an airport in Germany and know you'll never be close again. Or when you graduate from college and there are bubbles in your chest that are a mixture of nervous anxiety and optimistic excitement. When you hold your niece for the first time. When your cousin, after just doing something amazing, tells you that your support and encouragement inspired him towards that. When you make the decision to completely overturn your life to pursue a pipe dream and that moment that you realize the dream is going to come true. A first kiss. Then that first, intentional kiss. A perfect night out on a New York summer night. Sitting around a fire in the middle of nowhere in Maine. Standing over a roaring waterfall in Argentina.

There is a lot I don't have in my life. But sometimes we miss the trees for the forest. From the outside, perhaps it seems I don't have very much. And yet if you strung together all my perfect moments, it could be just as beautiful as the fog settling over the Golden Gate Bridge on a perfect San Francisco fall morning.

In San Francisco, the beauty was blatant and intentional. I loved it. I'm not sorry. But I realized that there are other kinds of beauty. Believe it or not, New Jersey was beautiful back when I lived there so many years ago (and probably even now). And where I live now is very much the same. It is easy to overlook. When I first moved here from San Francisco, I just viewed it as a means to an end. Good enough, but nothing special.

I don't feel that way anymore. It's not a beautiful place. That is true. But yesterday, I realized a cherry blossom tree has been growing in my front yard for the last three years and I never noticed it until then. In the fall, little yellow leaves gleam against the sun and sprinkle down onto the sidewalk on my way to work. In the heavy rains, everything turns a deep shade of green. Today, when I was walking home, another day of working late hours and not getting home before sundown, these very large dark trees waved out to me against the midnight blue sky. And it's not a beautiful place. But it will do.

***

Once upon a time, and this really was once upon a time, that far back, so far back that sometimes I can't believe I've been alive long enough for it to have been that far back, I used to get these letters (paper letters, no less) from the love of my life. Or what I call the love of my life, but I'm not dead, so who knows, that remains to be seen. We were all angst in those days, and back and forth's of what if's and maybe's and if only's. He was a very good writer, and I blame (or credit) that as to why I fell so hard for him. He had that Hemingway economy; he could explain better in five words what I couldn't quite put my finger on in five hundred. Once he wrote me a letter, and I don't honestly remember what it was he was turning over in his head or confessing to me. It was something that at the time twisted my heart in knots, but now it just seems likely to have been variations on a theme of wanting something to work out that was never destined to work out. He wrote some very anguished lines, the specifics of which I don't remember.

And then in the next paragraph, probably more to himself than to me, he wrote, "Pause. Take a sip of tea." And the entire tone of his letter changed after that.

Such a stupid, simple little phrase. Sometimes I don't actually fix myself a cup of tea. But I think of that saying all the time. I sometimes think he was put in my life just so that he could deliver that line. For lo and behold, I can be the queen of hyperbole and overanalysis and anxiety. I used to get crippling stomach aches when I was a child from just the thought of going to school. And every once in a while, I get into such spirals. A shame spiral, or a rage spiral, or a stress spiral, and I think the sky is going to fall on my head, and I hear this violent crescendo leading up to some fatal moment.

Then I take a slow, deep breath, let it out and calm myself. It's not always a cup of tea. Sometimes it's Dylan telling me, "all you can do is do what you must." Sometimes it is going to bed and forcing myself to believe that tomorrow is another day, another chance. Come to think of it, he and I read Candide together in college, and I don't know if all is for the best in this purportedly best of all possible worlds, but I do know that taking a breath, pausing, taking that sip of tea, it's a good way to cultivate your gardens.

endless numbered days

I feel this every day, but some days I feel it more than others:

"For it is true we can seldom help those closest to us. Either we don't know what part of ourselves to give or, more often than not, the part we have to give is not wanted. And so it is those we live with and should know who elude us. But we can still love them - we can love completely without complete understanding." - Norman Maclean

Sometimes my heart feels so full and at the same time so useless.

destroy the middle, it's a waste of time

I'm having another one of those episodes.

I am not posting much these days. Work is exacting an impressive toll on me, more than I thought it would. The other day, I realized I don't have a lot of patience for drama in my social life because work is enough of an emotional rollercoaster. I almost cried in a patient's room (and for the record, in case it's not been made clear before, I usually have non-functioning lacrimal glands as a general rule. I remember one time I was upset about something personal, and tried to cry, thinking it would help to let it out, and nothing happened) because she said she felt badly about being nervous about undergoing a stem cell transplant. The woman is in her late 20s, has 5 children, had a full-time job, and developed acute myeloid leukemia, and after she managed to get a remission, she relapsed just as she was getting lined up for a stem cell transplant. It's fine to write it like that, and make it sound like it's all happening to her. After all, in the end, it is all happening to her. But she was 25 weeks pregnant when she first came into the hospital, and I was the one who got to tell her of her diagnosis. I got to explain the not-benign chemotherapy regimen and its side effects, which we administered to this woman while she was pregnant. I got to tell her that her the good news that her repeat bone marrow showed no evidence of leukemia. I waited it out with her from afar as she delivered her baby and then I'm the one who got to rip her away from that new baby to give her consolidation chemotherapy to keep her leukemia away. I'm the one who got to arrange transfusions for her when she finally got home. I'm the one who got to discover that she had an allergic reaction to transfusions and needed a special suspension of platelets to keep from having hives and rigors. And I'm the one who got to tell her that the leukemia was probably back. And now it is, and she is getting chemotherapy again, and she tells me she is nervous. I involuntarily laughed and then choked up all at once. It was highly unprofessional but she didn't mind. I  told her it was okay to be nervous- her doctors are nervous for her and we're not even the ones going through it. We had this uncomfortable moment of silence in which it was clear we just were no longer doctor and patient- it's an odd thing when you cross over like that. All of a sudden, we were in a different territory. Two people navigating a difficult journey together, different stakes, different roles, but both in it, all the way in it. And I knew, just at the same moment, that this was very dangerous. So yeah, I don't need a lot of drama with this sort of thing a natural byproduct of my career (which doesn't even feel like an appropriate way to describe my job, but it would be pompous to call it anything else).

And I find, yet, that I have capcity for so much rage still. About stupid things (like television shows, and I have since deleted that portion of this post, because after posting it, it suddenly seemed stupid and unimportant) and horrible things, like three innocent people getting shot in North Carolina, one Indian grandfather being injured in an arrest, and the disturbing fact that the man was stopped because he was mistaken for a black man (thinking about the reality of what that means enrages me on so many levels that I have to step away and take a deep breath). But all that rage gets quelled by the sad realities that I often see with this work- sudden deaths or long, drawn-out expected deaths. I treat cancer patients so they know what they're contending against, but it doesn't make it all that much easier. Life is short, and precarious. The world tends towards entropy. I wish we didn't have to contribute to that entropy but sometimes it's important to shift the focus to what you can't control. I am going to strive to do better.